"High Risk Birth" - Defined by Whom?

In the last 5 years working for Maternity Coalition I have worked tirelessly to help establish one-to-one midwifery care across Australia. I am passionate that women can choose a midwife in any setting, but especially at home as I have experienced the beauty of homebirth. I do not at see myself as conservative or someone who 'sells out' in my role as an advocate. In the last year however I have been forced to reassess all of this. After 4 very normal pregnancies with stunning, intervention-free homebirths I was greeted with the news that I was having twins. In a split second I plummeted into the category of 'high-risk' - but did I really, and who defined it anyway?

Breech birth, vaginal birth after caesarean (VBAC) and twins birth can carry additional risk. The risk must be measured rationally however. The risk of uterine rupture for example after a primary c/s is not quite 1%. The vast majority of Obstetricians do not support women to achieve a VBAC. Many paint a picture of fear and death citing uterine rupture as a compelling reason to elect for a repeat caesarean. The risk of spontaneous abortion after amniocentesis is 1-2%. This test is routinely offered to women over 35 without any of the trappings of death and injury.

Before I was aware I was carrying twins I had planned another homebirth. I very much look forward to it. My first thought was “My homebirth is out the window’. Although I resist becoming a prisoner to the language of obstetrics that sees women as deficient beings in need of rescuing, I think some of it had rubbed off. In our advocacy we spend much of it demonstrating that midwifery care should be a mainstream option, but also accept the obstetric line that breech and twins and VBAC belong within a high-risk category. Now with a label threatening to choke me I sat back and thought, “Where is the individual rights of the woman and her body here?’

Very few women would knowingly put their baby or themselves at risk. Why then are women with 'special needs' granted less insight or knowledge of their body's capacity or their baby's wellbeing? Again we know the answer. It is because current obstetric practice in Australia is not about women, or even babies. It is about fear and control, the necessary ingredients in keeping maternity services dominated by the medical profession, and keeping the birthing of babies as big business.

After the huge shock I researched obstetric management of twins. It seemed at best if I fought hard I could give birth to my babies vaginally, but I would be very likely to be pressured to have an epidural (for the fast removal of twin 2, via c/s or forceps), I would also be pressured to have constant foetal monitoring. In the event of twin 2 presenting breech I would be likely to have a very managed birth (via forceps). In the event that I had not given birth by 38 weeks, induction would be strongly recommended. Of course the far more acceptable option would be an elective caesarean section again at 38 weeks. Despite many twins being born by caesarean section, like many obstetric practices it is not supported by evidence.

"Virtually no data from controlled trails are available to help determine the choice between vaginal birth and caesarean section for women with multiple pregnancy. A single trial has assessed the effect of caesarean section for delivery when the second twin was in a non-vertex presentation. As would be expected, maternal febrile morbidity and need for general anaesthesia was increased with caesarean section. No offsetting advantages in terms of decreased fetal or neonatal morbidity or mortality were found." Enkin et al 3rd Ed Guide to effective care in pregnancy and childbirth ... p.146

At 38 weeks my babies would be smaller and more likely to need additional care. In the event of a caesarean section I would need to recover from major surgery and at the same time attempt to breastfeed 2 babies and care for another 4 children. This was considered a safe option? I was very fortunate to be sent the now out of print book, “Having Twins’ by Elizabeth Noble (copies can be found on Amazon.com etc). This text reaffirmed my gut feeling that although a multiple pregnancy required some special care through nutrition and rest there is no reason that twins should be treated as high risk. The misconception that all twins arrive early was a consistent theme. Why does one neglect the power of a woman's mind in determining when and how she gives birth? Currently there are very few practitioners who affirm a woman's ability to carry twins to term. In my case I gave birth to two, three-kilogram babies at 40weeks, 1 day. With the exception of my midwives everyone I spoke to would say “You won't go full term’ “You'll have these babies early’ “No –one carries twins to term’. Interestingly the women I spoke to who had birthed twins at home or at least been cared for by an independent midwife all went very close to term. Those who birthed in hospital had to fight off the routine 38-week induction but with supportive care they all achieved term babies at 39 to 40 weeks.

This was very welcome news. I told my babies daily that they would grow to term. I did not give a thought to the fact that I would birth premature babies. Living in rural NSW this would have been disastrous for our family and myself. I would have been hours away from home and our children. I was fortunate enough to read a fascinating book called Pre-natal Parenting by US Neonatologist, Frederick Wirth. After 35 years seeing the often tragic consequences of premature birth, Dr Wirth researched how the mind affected the body. He makes a compelling case for women to focus on positive and loving thoughts throughout their pregnancy; Guiding families to address relationship problems and potential fears to enable not only a healthy pregnancy and birth but also an affirming start to bonding and parenting a new human. He says:

“Prenatal visits help your healthcare provider recognize complications during pregnancy, and they do an excellent job, but too many patients believe that their pregnancy outcome depends solely on the quality of their medical care. The success of your pregnancy also depends on the psychological and spiritual content of your life.’

I was intrigued; Dr Wirth must be supportive of midwifery care and the option of homebirth (due to the very model of care being holistic blending health care into the social fabric of our lives). Dr Wirth in fact described the first homebirth he attended as the most beautiful, despite witnessing hundreds in the hospital system. He felt like an intruder and wanted to leave the couple to do what they were doing so beautifully, creating a safe and loving environment to welcome new life.

I was buoyed by what I read. I progressed full steam with confidence that the only place to have my babies was at home full term. Instinctively I knew that home was the safest place to give birth (in the absence of medical complications or conditions). Importantly I had also proven clinically that it was also much safer for me to be cared for by midwives at home.

How could my babies be safer with a routine induction at 38 weeks, when they were more likely to need resuscitation and medical care? How would constant foetal monitoring assist when studies have shown it's routine use has seen no improvement in outcomes only an increase in caesarean section? How would my babies or I be safer with an epidural that would prevent me being upright, the proven best physiological position for normal birth? How would I be safer being denied deep water for pain relief? (Do you know of a hospital that will enable a woman birthing twins to use a birth pool for pain relief in labour and to give birth if she wishes?).

As my pregnancy progressed I remained healthy and happy. I had decided to have 3 ultrasounds one at 20 weeks (soon after I realised I was carrying twins) one at 28 weeks and another at 34 weeks. All these scans revealed healthy babies of a good size. I was carrying fraternal twins (in all likelihood) I had a single placenta that had probably fused. One baby was head down the other breech. This is the only interaction I had with obstetrics. I used technology in a limited way to keep my home birth plans alive.

Like many women in a way I would of liked to have given birth at around 38 weeks, I felt pretty heavy. Although at 39 weeks I felt excellent (even had a spring in my stride). My midwives said I looked 'too good' to be close to birth!

At 40 weeks I decided it was really time to meet my babies and they must have agreed. My midwives and doula were with me. On the last day we enjoyed time together with the kids, had a nice meal together and all went to bed. At 1.30am my waters broke with a huge gush. By 2 am I had strong contractions. I then woke my midwives and doula, as I was conscious the pool needed to be filled. My labour progressed furiously. I could feel twin 1 moving down. I entered the pool with the water level a little low. The pain relief was instant and considerable. Our digital camera revealed I was only in the pool for 7 minutes before our first baby was born. The water was just deep enough! Amazingly I put my hand on her head and felt her shoulders rotate as she was born. I also caught her and drew her close to me revealing her gender. It was an awesome feeling to catch my own child (something I had been previously unable to manoeuvre).

My husband entered the pool at this stage. Contractions started again, 6 minutes after our first baby was born. I was very uneasy holding our first baby with a contraction winding up. Paul held her as I got on with birthing our second baby. The cord had stopped pulsing with baby 1 and I asked that it be cut. Although this would not have been by preference the cord was not overly long and I felt very uneasy still being connected and contracting. The midwives later said they were happy to hear me quite anxious about all of this, as it was a clear sign that baby 2 was very near.

My midwife announced there was “a foot’ and I very clearly thought “OK here's our little breech babe, just remember her head will be last, brace yourself! I had no fear about her being breech. Her birth was easy. I do concede however, that she was a twin with a smaller head than most (33cm) and I had just birthed a baby. My midwives were remarkable. One simply gave baby 2 a gentle push back towards me (as the weight of her head prompted her to move up towards my back rather than the front). Both Paul and I then welcomed our 2 girls in the warm pool. Both babies were born with APGAR's of 9 and 9. I had a slight graze. I had a physiological 3rd stage, birthing a vary large and healthy placenta 45 minutes later. I had minimal blood loss and recovered beautifully

The photo on the front cover was taken 8 minutes after our second baby was born. I guess it says it all really. Our baby's entrance into the world was sacred and safe. In comparison they could have been cut or pulled from me before they were ready most likely with worse results. The irony is that the latter choice is seen to be 'safer'.

It is time to re-think risk. I have explored twin birth through my own experience. VBAC and single vaginal breech birth are other 'risk' categories that need to be examined. The fear that surrounds VBAC is totally unwarranted. I believe the majority of women attempting VBAC are set up to fail, vaginal breech is so rare in the hospital system that I believe it is unsafe. Not unsafe itself but unsafe due to totally inexperienced practitioners. Other than independent midwives I know of one Obstetrician experienced in breech birth with a gentle 'hands-off' approach.

In relaying this story I do not believe that all twins, some VBAC's or breech babies can or should be born at home. What I have learnt via research and through practical experience is that 'risk' is a conjecture from practitioners who have little if any understanding or faith in normal birth. Unfortunately birth in Australia is dominated by medical practitioners. These practitioners create labels of 'risk' often with little regard for research evidence. On the whole these practitioners only believe in the safety of birth after the event. To me this is most telling and explains our huge rates of intervention, and resultant morbidity.

If the pilot responsible for flying the plane you travelled on was only convinced air travel was safe after he had safely landed the plane what would you think? Would you doubt his competence as a pilot? Think perhaps he should get another job. Would you doubt the safety of the actual aircraft? Sadly most women do the latter, they allow medical practitioners to convince them that their body is faulty. Why not question the practitioner? After all most Obstetricians are male with no real way of truly understanding pregnancy and birth.

Post Script: As I write this our twins are 7 weeks old. I am happily breastfeeding them, they have grown beautifully 1.2 and 1.3 kg since birth! Raising twins is certainly hard work but the support I received from my midwives gave me such a huge head start. Thank you to Betty Vella, Robyn Gasparotto and Margie Perkins for your courage and commitment.

Comments

From a political perspective I think it is a mistake to try to argue from the perspective of Risk. The statistics are definitive - certain types of pregnancy and birth result in a higher likelihood of various adverse outcomes. The reality is that most of these risks are small and even if doubled or tripled, a small risk still remains a pretty small risk. However there is no point in trying to pretend that such things as twin births are not assosciated with increased risk, and succesful vaginal birth of twins or VBAC doesnt alter that truth, any more than sucessfully driving without a seatbelt would be evidence that seat belts are unnecesary. I believe the real issue is about whether or not you have the right to take that risk - and I believe you do. The problem is that the medical professionals have decided what for them are unacceptable risks and they are not able to understand that others may have different asessments of what constitutes unacceptable risk. And when well informed intelligent people make different asessments they resort to ridicule and name calling and using such labels as "irresponsible" and " crazy" and so on. To know that over 99% of the time a scar does NOT rupture means that for many women the idea of VBAC makes perfect sense.